Elderly male complaining of life‐threatening oral swelling

As the prevalence of oral lesions has increased in older adults, there is a strong interest in the oral health of older adults. In this vast group, there are several conditions more characteristic for the aging and elderly. In this context, there are conditions ranging from the nonneoplastic type, generally represented by inflammatory and reactive lesions, through to true neoplasias that might be of a benign or malignant nature. We aimed to present an aberrant case of life-threatening gingival maxillary pyogenic granuloma in an elderly patient. The patient, a 68-year-old man, sought attention complaining of “a large lump in the cheek that prevented him from eating”. Anamnesis revealed a painless growth that had developed over a period of 8 months. The extraoral exam showed a swelling in the left masseter-buccinator region causing extensive facial deformity. The oroscopy showed an edentulous patient, presenting an increased gingival mass with its largest diameter measuring approximately 9 cm (Fig. 1). Histopathological examination of the fragment removed by incisional biopsy revealed a fragment of conjunctive tissue devoid of epithelial lining and covered by granulocytic membrane, presenting dense leukocytic inflammatory infiltrate mixed with polymorphonuclear granulocytes, intermingled with neutrophils and numerous blood vessels of various calibers, featuring the diagnosis of pyogenic granuloma. The immunohistochemical analysis showed evidence of intense marking for CD31, CD34 and muscle-specific actin (HHF35) in blood vessels walls, demonstrating high vascular proliferation, characteristic of reactive lesions. The lesion was completely removed by local surgical excision in a hospital environment under general anesthesia because of the patient’s age and the large dimensions of the lesion. The present case reinforces the importance of a detailed differential diagnosis of gingival lesions in elderly patients. Among the non-neoplastic proliferative processes that affect the gingiva in the maxillary and mandibular region, we could include the peripheral giant cell granuloma, peripheral ossifying fibroma, plasma cell granuloma and pyogenic granuloma. In addition, the history of relatively rapid growth, reaching large dimensions in just 8 months, in association with minimal bleeding on trauma, led us to include other lesions with more aggressive behavior in the differential diagnosis: ossifying fibromixoid tumor, epithelioid hemangioendothelioma and angiosarcoma. The pyogenic granuloma is usually treated by surgical excision. Similarly to the procedure carried out in the present case, in addition to removing the lesion, it is fundamental to include a small safety margin in depth, including the periosteum, as well as removing the irritant factor, with the purpose of preventing recurrences. The present report, despite being rare because of the lesion dimensions, should warn professionals who routinely make diagnoses of different oral lesions to be permanently alert to the different clinical nuances that the most varied benign and malignant diseases might present in elderly patients, considering that the incorrect diagnosis of a lesion could lead to unsatisfactory results from an aesthetic and functional point of view, and impact negatively on the quality of life of these elderly individuals.

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